In the era of ‘patient safety’ and ‘evidence-based practice’ when great efforts to redesign systems and prevent errors have been made, it is expected that compliance to risk-reduction strategies becomes internalized in all health care professionals (Mahida, 2016). However, ‘not doing hand hygiene’, ‘fail to double check when administering a high-alert medication’, ‘not confirming patient identity’, ‘not marking the surgical site’ and ‘not using individual protection equipment’ are frequently seen situations in everyday care among caregivers. Considering that ‘the nurse carries personal responsibility and accountability for nursing practice’ (International Council of Nurses, 2012), are there reasons that justify these behaviours? Beyond system improvements and under an ethical perspective, it's time to think about moral and professional obligations about safety in health care. Several meanings for accountability are described in the literature. In a patient-safety perspective, being accountable is to be responsible for a professional practice that is planned and executed in the best interest of the patient and family, at the right moment and in the right way, following standards and protocols of quality and safety. Some definitions of accountability include ‘responsibility for professional actions; responsibility; being answerable to self and those who are influenced by one's actions; one's free choice and strong personal commitment to ensuring that a result is achieved’. Analyzing these definitions Krautscheid (2014) synthesizes professional nursing accountability as ‘taking responsibility for one's nursing judgments, actions and omissions as they relate to lifelong learning, maintaining competency and upholding both quality patient-care outcomes and standards of the profession while being answerable to those who are influenced by one's nursing practice’. In the early context of patient-safety movement, the system-based approach of errors led to a worldwide transformation of health care's culture from a punitive to a ‘no blame’ perspective, which states that the majority of errors are committed by well-meaning and dedicated professionals in an imperfect system (Moriates and Wachter, 2016). Errors are not only consequences of system failures but also result from professional's behaviour of not following safety standards and rules (Avelling et al., 2016). Although errors are a part of human condition, failing to perform the required safety steps represents an at-risk behaviour, a problem not embraced by system approach (Moriates and Wachter, 2016). The systemic approach of errors analysis proposed by Reason (2000) improved health care quality and safety, but non-intentional adverse events caused by errors are different from those initiated by violations, caused by health care professionals that habitually choose to ignore safety standards (Watcher, 2012). In complex health systems, individuals play a critical role in protecting patient and reducing harm, requiring health care professionals to be accountable for their practice and comply with their moral obligation to ‘do no harm’(Gilbert et al., 2009). An intensive care nurse is accountable for strengthening safe nursing practice and this behaviour should be expressed daily by actions that are synergic with the essence of nursing practice: the care and advocacy for preservation of patient's integrity and individuality. It's time to acknowledge that misconduct is different from lapses and can result in serious patient harm (Moriates and Wachter, 2016). All intensive care nurses are accountable for patient safety and should undertake self assessment to achieve performance improvement. Also, the health care system is accountable for developing the skills to confront disruptive behaviours and to argue in the institutional level to transform the system by putting the patient and family at the core of all decision-making process to provide the best intensive care. In developing countries like Brazil, the health care system has a wide variation in infrastructure and resources availability, affecting patient safety and the quality of nursing practice. In systems where multiple agents, government, institutions, leaders, teams and people contribute to the achievement of common goals, different effects can be produced on systems and it is difficult to identify one agent responsible for one particular effect. Such a situation called as ‘many hands’ embraces the basis of identification of a single agent responsible for an undesirable effect (Dixon-Woods and Pronovost, 2016). Many critical care nurses become demotivated with their practice environment because they face a wide range of problems that compromise patient safety. Such problems can be a result of system failure but others are frequently caused by disruptive behaviours and violations of standards and safety goals. Putting patients at the centre of our practice, striving to protect their individuality and integrity defines the accountability of those who chose to be a nurse, and supports nurses' role in the lifelong learning of health care system transformation and development.
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Jul 28, 2022
Samantha Horvath + 1
